This proposal is intended to build on and extend the work of the low back pain Patient Outcome Research Team (PORT). It is intended to provide more definitive information for refining and implementing clinical guidelines about lumbar spine surgery and its alternatives. This project will be based in the Department of Health Services at the University of Washington, with extensive involvement by the School of Medicine, the Group Health Cooperative of Puget Sound, and the Maine Medical Assessment Foundation. Specific aims of the project are: (1) for patients with sciatica or spinal stenosis, to compare long-term functional and work- related outcomes of alternative surgical and nonsurgical treatments; and (2) to assess the impact of back pain guidelines and health care reform efforts on regional and national trends in back surgery rates, reoperation rates, fusion rates, and nonsurgical hospitalization rates. To accomplish these aims, we propose continued long-term follow-up of over 600 surgically and nonsurgically treated patients in the ongoing Maine community-based cohort study. Also, we propose to analyze annually updated data from Washington State's hospital discharge registry, the National Hospital Discharge Survey, and Medicare claims, to assess responses to PORT-related activities, new guidelines, and state and national health care reform efforts. These analyses will employ validated analytic methods for case selection and comorbidity adjustment developed by the PORT, and can be accomplished relatively efficiently and inexpensively.